ELIGIBITY CRITERIA:

  • Referral from Service Providerswill require a copy of ALL relevant collateral information(including any assessments, discharge summaries & recovery documents)prior to the referral being triaged
  • All referrals will be triaged by the Clinical Team to assess eligibility and suitability for headspace Ipswich
  • Outcome of referral will be provided directly to Service Provider via email, telephone and or fax
  • General Practitioners are able to fax and or email a Mental Health Care Plan to headspace Ipswich instead of completing this referral form
  • headspace Ipswich works under Medicare Billing Model (MBS), this means young people are only eligible for up to 10 Sessions with Private Practitioners (Psychologists, Social Workers, Occupational Therapists)
  • headspace Ipswichalso has access to ATAPS Providers (Psychologists, Social Workers, Occupational Therapists) onsite where a young person are able to access up to 12 sessions if assessed to meet the criteria by the Clinical Team
  • For further information on services available at headspace Ipswich please access our website
  • Referrals from Probation and Parole require social history, information on convictions and pending legal matters including dates,prior to referral being triaged.Please note we are a voluntary service.

1. REFERRER (INDIVIDUAL COMPLETING THIS DOCUMENT)

Contact Name: Click here to enter text.

Position / Role: Click here to enter text.

Organisation: Click here to enter text.
Postal Address:Click here to enter text. Postcode: Click here to enter text.

Phone:Click here to enter text. Mobile:Click here to enter text. Fax: Click here to enter text.

Email: Click here to enter text.

Signed: ______

2. YOUNG PERSON BEING REFERRED (THESE DETAILS WILL BE USED TO CONTACTED THE YOUNG PERSON/PARENT, GUARDIAN)

First Name:Click here to enter text. Surname: Click here to enter text.

Date of Birth:Click here to enter text. Age:Click here to enter text. Gender: ☐M ☐F ☐Other:Click here to enter text.

Address: Click here to enter text.

Suburb:Click here to enter text. Postcode:Click here to enter text. State:Click here to enter text.

Home Ph:Click here to enter text. Mobile:Click here to enter text.

If Consent provided by young person, please provide details of their Parent/Guardian:
Click here to enter text.

Mobile:Click here to enter text.

NOTE TO REFERRER

Please provide as much information as possible as it ensures the best quality of care, outcome and if required referral is afforded to the young person being referred.

If the young person is experiencing high levels of distress which may result in harm to themselves or others, please refer them directly to their local Emergency Department as headspace is not a Crisis Service or equipped to manage these types of emergencies.

3. REASON FOR REFERRAL

☐Mental Health ☐Physical Health ☐Vocational/Social ☐Alcohol/Other Drugs ☐Other (please specify): Click here to enter text.

4. INFORMATION ABOUT THE YOUNG PERSON

(If Applicable) Risk to self or others (Include self-harm/suicide attempts, violence, threats of violence, vulnerability).

Date / Type of Behavior / Reasons for Behavior / Outcome/Treatment Provided

(If Applicable) Other Agencies/Health Care Providers who are currently involved with the Young Persons Care: (e.g. Government, Non-Government, Psychiatrists, GP’s and Community Services)

Name of Organisation / Contact Person / Address / Phone

5. PRESENTING ISSUES

☐anxiety ☐pain management issues ☐adhd / add ☐refusing school

☐family problems ☐financial difficulty ☐depression ☐self-harm

☐physical abuse ☐loss of appetite ☐eating problems ☐suicidal

☐relationship issues ☐physical disability ☐drug abuse ☐crying

☐harm or threats to others ☐sexual abuse ☐stress ☐aspergers / autism

☐domestic violence ☐ptsd / trauma history ☐body image

☐emotional abuse ☐bullying others ☐pending legal matters

☐social problems at school ☐difficulty sleeping ☐intellectually impaired
☐presentation to ed or hospital ☐history of hospitalisation

☐past or present contact with child safety ☐hallucinations & delusions

☐other:Click here to enter text.

Do you have any final comments or relevant information?

6. Consent Of Young Person Being Referred

I am aware that this referral is being made. I understand that I can withdraw from this referral or from the referred service at any time.
Please NOTE: Referrals will not be processed without signed consent.
I give permission for headspaceIpswichto use my contact details above for future contact with me. / ☐Yes ☐No
I give permission for the staff of headspace Ipswichto obtain relevant information from referrer pertaining to this referral / ☐Yes ☐No
I give permission for headspaceIpswich to contact the referrer and advise once an appointment has been arranged. / ☐Yes ☐No

Signed: ______Print Name: Click here to enter text. Date: Click here to enter text.

If under 18 years of age authorisation ideally should be provided by a parent/ guardian.

Parent/Guardian Signed: Print Name: Click here to enter text. Relationship: Click here to enter text.

7. thank you for your referral

Please return this form to headspace Ipswich

Address: 26 East Street, Ipswich, QLD, 4305

Ph: 3280 7900

Email:

Fax: 3280 7999

8. What Next?

  • On receipt of a referralheadspaceIpswichwill contact the service provider to advise of outcome and then if applicable will contact the young person for a phone triage and or in addition to arrange a face to face appointment.
  • All triage contact will be with a headspaceIpswich Intake and Assessment Officer.

headspace National Youth Mental Health Foundation is funded by the Australian Government Department of Health
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Headspace Ipswich Referral Form V3